Provider Demographics
NPI:1053454108
Name:SANTOS-MATA, ELENITA P (MD)
Entity Type:Individual
Prefix:DR
First Name:ELENITA
Middle Name:P
Last Name:SANTOS-MATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4851 W PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4010
Mailing Address - Country:US
Mailing Address - Phone:225-658-7636
Mailing Address - Fax:225-658-7634
Practice Address - Street 1:4851 W PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4010
Practice Address - Country:US
Practice Address - Phone:225-658-7636
Practice Address - Fax:225-658-7634
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA07399R2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1372617Medicaid
LA1372617Medicaid